The Making of Mind. A R Luria
WORLD WAR II was a disaster for all countries, and it was particularly devastating for the Soviet Union. Thousands of towns were destroyed, tens of thousands of people died from hunger alone. Many millions, both civilian and military, were killed. Among the wounded were thousands who suffered brain injury and who required extended, painstaking care.
The unity of purpose of the Soviet people so clearly felt during the great Revolution and the subsequent years reemerged in new forms. A sense of common responsibility and common purpose gripped the country. Each of us knew we had an obligation to work together with our countrymen to meet the challenge. We each had to find our place in the struggle either in the direct defense of our country, in the preservation and expansion of industry, which was removed to remote regions of the country, or in the restoration of the health and abilities of the wounded. My institute was assigned to the latter task.
The medical corps of the Soviet army was superbly organized, earning great respect during the war and afterward. The aging Bourdenko, former head of the Institute of Neurosurgery, was by then totally deaf. But he retained his acute clearness of mind and was named surgeon general. Under his guidance and through the efforts of a group of able physicians headed by H. Smirnov, a superb system of medical care was organized.
The care of those with brain injuries was organized by N.I. Graschenkov, head of the Neurological Clinic in the Institute of Experimental Medicine and later deputy minister of health in the USSR, a neurologist as well as a neurosurgeon. He saw to it that soldiers with brain and peripheral nerve injuries received emergency medical care at the front during the first hours after being wounded. They were then sent to the Institute of Neurology in Moscow, which had been transformed into a neurosurgical hospital. Patients who required further care and special treatment were transported under careful supervision to rehabilitation hospitals in the southern Urals.
I was commissioned to organize such a hospital in the opening months of the war. I chose as the site for our hospital a newly established 400-bed sanitarium in a small village near Cheliabensk. I organized the construction of laboratories and therapeutic training rooms and recruited a team of former colleagues from Moscow to work with me. Within a month the hospital began its work.
We had two major tasks. First, we had to devise methods of diagnosing local brain lesions and of recognizing and treating complications such as inflammation and secondary infection that were caused by the wounds. Second, we had to develop rational, scientifically based techniques for the rehabilitation of destroyed functions.
Although our team of thirty researchers began with a general idea of how to carry out the work, we realized that specific solutions to the incredibly complex problems we faced could emerge only from the work itself. I personally brought to the task a small store of practical experience from my five or six years of work in neurology and on neurosurgical wards as well as the beginnings of an experimental approach to brain lesion study. The hospital was modestly supplied with neurophysiological devices, neurosurgical apparatus, and the basic equipment of a histology laboratory. Our most important resource was our dedication to the task. We were required to diagnose and treat a full complement of disturbed mental functions, ranging from defective sensation, perception, and movement to disturbances of intellectual processes.
We worked in the Urals for three years and then were transferred back to Moscow, where we continued this work after the end of the war. Paradoxically, this period of disaster provided an important opportunity for advancing our understanding of the brain and of psychological processes. It was during the war and its aftermath that neuropsychology became a full-fledged science.
My prewar studies proved to be an invaluable base from which to begin. But we had to broaden our general approach both to include the many new and terrible brain injuries made common by modern explosives and to provide a rational basis for restoring psychological functions. Although on their face these two needs appeared to be different, the logic of our approach made the procedures for diagnosing and describing the nature of cerebral dysfunction entirely compatible with the therapeutic techniques that were called for by different forms of damage.
In some cases we found chemical agents that disinhibited traumatized functions of certain kinds. When applicable, chemical therapy was particularly useful in speeding recovery. The basic phenomenon in such cases seemed to be a kind of “state of shock” which rendered part of the brain inoperative. As a rule, however, our basic methods of restoring function required us to combine chemical therapy with a program of retraining and functional therapy. One area in which we developed training methods for the reorganization of a functional system was writing.
The work of Bernshtein illustrated the way in which organized movement, or locomotion, constitutes a complex functional system, depending on the particular constellation of muscles used and the particular kind of motion involved. Walking, running, and playing soccer all involve leg muscles, but the system of activities is clearly different in each case. Moreover, if some of the muscles, or one of the systems of muscles, ordinarily involved in locomotion is disrupted, it is possible to compensate by using other muscles and systems of muscles that remain.
When there is severe damage, it is possible to supplement existing muscles by the addition of prosthetic devices which can be included as part of a functional system to permit adequate, if not normal, locomotion.
It should be apparent that if the operation of intellectual processes is thought of in terms of functional systems instead of discrete abilities, we have to reorient our ideas about the possibility of localizing intellectual functions. It is easy enough to reject both the holistic notion that every function is distributed equally throughout the brain and the idea that complex functions are localized in narrowly specified areas of the brain, but it is difficult to find an intermediate position. Our solution has been to think of the functional system as a working constellation of activities with a corresponding working constellation of zones of the brain that support the activities. An excellent example of such an activity, which clearly could not have been coded in the human brain in a purely organic fashion because it involves the use of man-made tools, is writing.
The task of writing a particular word, whether independently or from dictation, begins with the process of analyzing its phonetic composition. In other words, the activity begins by breaking down the sound stream of living speech into its individual phonemes. This process of phonetic analysis and synthesis is unnecessary only in the few languages, like Chinese, that use ideographic transcription, which represent concepts directly by means of symbols. In other cases those areas of the brain responsible for analysis of acoustic-verbal information play a decisive role in the analysis of normal speech into stable phonemes. When these parts of the cortex are injured and the isolation of stable phonemes from the flow of speech becomes impossible, as often occurs in sensory aphasia, writing is disturbed. In such cases, the disturbance takes the form of the substitution of similar phonemes, such as b for p or d for t, the omission of certain letters, and other indications that the speech flow has been inadequately analyzed. Substitutions of meaningless combinations of letters like gar for car illustrate this kind of disturbance.
In cases of kinesthetic, or afferent, motor aphasia a slightly different kind of disturbance in writing is apparent. In such patients “articulatory” analysis, which is involved in the pronunciation of a required phoneme and which helps the speaker to distinguish it from other phonemes, thereby clarifying the phonetic structure of the word, is disturbed. In the first stages of learning to write, saying a word often helps the writer to write it correctly. By pronouncing the word, he has analyzed its articulation. By the same token, when an individual can no longer correctly articulate a word, there are articulatory errors in his writing. Common errors in such cases are substitutions of letters that are similar in their articulation, such as b for m, and n for l or t, so that for the Russian word stol one gets the word slot, and instead of the Russian word slon one gets ston.
Once the speech stream has been correctly analyzed, the writer must translate the isolated phonemic unit into its proper visual or graphic unit. He must choose the necessary visual sign from the large number available, matching it and its spatially organized strokes with the auditory stimulus. These requirements of the task of writing involve the tempero-occipital and parietaloccipital regions of the cortex, which are responsible for spatial and temporal analysis. If these zones of the cortex are injured, the spatial organization of graphemes is disturbed. Similar letters are substituted for one another, there are mirror image mistakes, and even though the phonemic analysis of sound may be intact, writing is distorted.
The steps described so far are only preparatory to the actual act of writing. In the next stage, visual images of letters are transformed into motor acts. In the early stages of learning to write the motor process of writing consists of an extended series of steps, and the changes from one step to another occur as discrete acts. As the process of writing becomes more automated, the motor units increase in size, and the person begins to write whole letters at once, or sometimes firmly established combinations of whole letters. This can be seen in the work of an experienced typist who types established combinations of sounds with a single group of movements. When writing has become an automatic habit, some words, particularly those that are familiar, come to be produced by a single, complex movement and lose their link-to-link sequential nature. When writing reaches this stage, different parts of the cortex play a decisive role in the process, notably the anterior portions of the “speech zone” and the lower portions of the premotor area. A lesion in this part of the cortex interferes with transference from one movement to the next, and consequently writing becomes deautomatized; sometimes the correct order of letters in a word is lost or certain elements of a word are repeated. This syndrome is often linked with kinetic motor aphasia.
Finally, writing, like any activity, requires the maintenance of a constant purpose or plan and continuous feedback concerning the results of the action. If the patient cannot maintain a constant purpose and if he is not receiving continuous feedback concerning his actions, he loses his stability of purpose and also loses track of what he is doing. Under these conditions, writing also becomes defective, but here the defect becomes apparent in the meaning and content of what is written. Irrelevant associations and stereotypic expressions intrude in the writing processes. Such mistakes are commonly seen in patients with frontal lobe lesions. From this description one can see that many different regions of the brain are involved in the complex functional system that underlies writing. Each area is responsible for a particular part of the process under normal conditions, and a disturbance in any one area will have distinctive effects on subsequent writing.
There are several questions to ask and basic principles to apply in diagnosing and treating disruptions of complex psychological functioning by brain lesions. In making a diagnosis, we ask which link, or links, in the normal system of the working constellation of brain zones is disturbed in the patient. Once our analysis has indicated the area of disturbance, we can undertake treatment. Treatment and diagnosis are not as separate as they seem. In the course of trying to treat a particular disturbance we often modify our diagnosis. After determining which links of the activity are disturbed, we try to determine which links remain untouched. In treating the disturbance, we try to use the remaining links, which we supplement with external aids to reconstruct the activity on the basis of a new functional system. A considerable period of retraining may be necessary to build and maintain the new functional system, but at the end of the period it should be possible for the patient to engage in the activity without external assistance. During this process we try to find ways to give the patient as much feedback as possible concerning both the defect and its effect on the patient's actions. This feedback gives the patient information that is crucial to the reorganization of the required functional system.
These principles are stated here in a rather abstract manner, but in practice they are anything but abstract. Both to illustrate the basic principles of using the reorganization of functional systems as a way of restoring damaged functions and to show how the analyses and treatment of such functional systems provide information about the brain and the organization of psychological processes, I will describe some of the work we did during the war and immediately afterward.
Afferent motor aphasia, in which a lesion of the posterior portion of the motor speech area has disturbed the kinesthetic basis of speech articulation, was one subject of study. Essentially this aphasia consists of a disturbance of the act of articulation, resulting in an inability to find the articulation required to make a particular sound. Disturbances of articulated speech can of course be caused by a great variety of different local lesions. Before a program of rehabilitiation can be organized for a patient, a careful analysis must be made to determine the fundamental factors underlying the particular disturbance. It must be clear that the symptoms are caused by kinesthetic aphasia and not by kinetic or another kind of aphasia that sometimes involves similar individual symptoms. The aim of our retraining program is to reconstruct the functional system of articulated speech by replacing the disintegrated kinesthetic schemes, using new, extra kinesthetic afferent systems. By raising the articulatory processes, which are automatic and unconscious in their natural states, to the level of consciousness, we can provide the patient with a new basis for restructuring articulation.
Usually not all levels involved in the construction of movements of the articulatory apparatus are injured to the same extent in afferent motor aphasia. It is often the case in patients with brain injuries that the imitative or symbolic movements of the articulatory apparatus disintegrate while the elementary “instinctive” and “purposive” movements of the tongue and lips remain intact. Thus a patient who cannot touch his upper lip with his tongue or spit when the doctor asks him to can do so easily in real, spontaneously arising situations. Consequently the most effective method of rehabilitation is one in which the therapist first begins by discovering the residual movements of the lips, tongue, and larynx. These are used in training the patient to produce sounds. For example, to get the patient consciously to produce the sound of the letter p, the therapist gives the patient a lighted match, which he instinctively blows out when the game reaches his fingers. This is repeated many times in all sorts of varied circumstances. In the course of such practice, the patient's attention is gradually concentrated on the components that make up the movement. The therapist shows the patient how to position his lips so as to pronounce the corresponding sound and how to coordinate his movements with the puff of air. To make the patient aware of the components of the movement, the therapist presses and rapidly releases the patient's lips while applying pressure to his chest to produce the coordinated puff of air.
Other sounds are formed in similar ways. The sounds of b and m are produced by a coordinated set of bodily acts which are similar to the p sound, except that the regulation of the puff of air that produces them requires a slightly different position of the soft palate and the degree to which the lips are compressed. The sounds v and f are formed from another complex set of coordinated movements which have in common biting the lower lip. To pronounce the sound u, the patient forms a round, narrow opening by placing his mouth around a pipe. For the sound a, his mouth is opened wider. Based on this kind of analysis of the articulatory requirements of every sound, each program for relearning to articulate speech sounds begins by drawing on some real, purposeful movement of the lips, tongue, and larynx that has been left intact. The patient is then made aware of this movement and with the help of various external aids is taught to reproduce them consciously.
Among the external aids we have found useful are diagrams, mirrors, and even the printed letter. A patient can be taught to articulate a sound by reading the structure of the sound from a diagram that depicts the relative positions of the motor elements required to make the sound. A mirror is also helpful. Sitting beside the therapist and observing in a mirror the articulations that lead to the pronunciations of a particular sound, the patient begins to construct his own articulations. For a long time the visual scheme and the mirror are the patient's principal aids in learning to pronounce different sounds. Then the written letter begins to be used. Writing is a powerful auxiliary device because it allows the patient a means both for placing different variants of the same sound in the same category (all p's are like m's, v's are like f's) and for differentiating sounds closely related in their articulatory compositon (b versus p). The use of these auxiliary devices, especially the written letter, leads to the radical reconstruction of the entire functional system of articulation so that it is carried out by completely different mechanisms. Such reconstruction, using a complex, culturally mediated, external system of signs, is one illustration of the principle that higher functions can be used to replace lower ones in the restoration following brain injury.
This type of reconstruction is difficult and demands painstaking work. Every operation that the patient normally carries out automatically without thought must become conscious. As a rule, once the articulations of the required sounds are found, the patient easily passes on to the articulation of syllables and words. For a long time, however, the restored speech sounds very artificial, and the conscious character of each movement clearly reveals the difficult path of reconstruction. Only gradually does the patient begin to speak more automatically and normally.
The course of retraining in cases of semantic aphasia differs greatly from that in motor aphasia. Semantic aphasia occurs in patients who stiffer damage to some part of the parietal zone. They have difficulty perceiving certain kinds of relations and combining certain kinds of details into a single whole. Underlying these difficulties is a disturbance of their spatial functions.
In contrast to those suffering from motor or kinetic aphasia, patients with this type of lesion have no difficulty articulating words. They also retain their ability to hear and understand most spoken language. Their ability to use numerical symbols and many different kinds of abstract concepts also remains undamaged. They can repeat and understand sentences that simply communicate events by creating a sequence of verbal images, such as: “One sunny day it was absolutely quiet in the forest. The fir trees were not stirring. Flowers were sprinkled through the fresh, green grass.
Their particular kind of aphasia becomes apparent only when they have to operate with groups or arrangements of elements. If these patients are asked, “Point to the pencil with the key drawn on it” or “Where is my sister's friend?” they do not understand what is being said. As one patient put it, “I know where there is a sister and a friend, but I don't know who belongs to whom.” This is typical of patients suffering from semantic aphasia who are unable to grasp immediately the relations between various elements of a grammatically complex construction.
Long practice, mechanical learning, or practical training do not, as a rule, improve the ability of these patients to grasp the conceptual relations involved in such constructions. Grammatical constructions that are within the grasp of a five- or six-year-old child remain incomprehensible even to highly educated patients whose ability to synthesize words simultaneously is disturbed. Our basic method of therapy in such cases was to avoid the difficulties that are insuperable for the patient and to replace the direct perception of relations with successive reasoning using various external devices.
These methods were usually used when we taught the patient to understand inflected or prepositional constructions. For example, we gave patients who could understand the relation expressed in the phrase “the circle above the triangle” or “the triangle above the circle” the following drawing, which they could use to break down the complex relationship into simpler ones:
Beside each shaded figure is a caption that converts the relative preposition (above, below) into an absolute expression (at the top, at the bottom). This drawing enabled the patient to replace the incomprehensible relationship “the circle above the triangle” with ones that he could directly understand: “the circle is at the top, and the triangle is at the bottom.” By breaking down the complex grammatical formula, the patient could master the relations it denotes even though he could not experience the “direct impression of relationship” which is normally essential to understand such phrases successfully.
We used analogous rehabilitative methods when patients failed to grasp such possessive relations as the “father's brother,” or the “sister's friend.” Although our particular therapeutic techniques for overcoming the patients' defective comprehension of such possessive relations critically depended on the structure of the Russian language, which changes word endings to mark grammatical relations, the basic method remained the same. The patients were taught to break such phrases down into a simplified form in order to carry out the appropriate analysis. Indirect analyses of complex grammatical structures are often the only way patients suffering from this kind of aphasia can understand these constructions. With time, this process becomes increasingly rapid and automatic. Only in rare cases, however, can it become so automatic that it resembles the “direct perception of relations” by which normal individuals understand such phrases. Although reconstruction of the functional system does not restore the damaged cortical function in its original form, it has resulted in the desired outcome in all cases that we analyzed.
Not only may individual functions be disturbed as a result of brain injury, but the more generalized functional system that underlies active thinking can also be disturbed as a result of injury to the frontal lobes, particularly in the vicinity of the premotor zone. Distinctive in this kind of injury is the disturbance of spontaneous thinking. Patients with frontal lobe lesions show no gross disturbances of the structure of individual mental operations. The logical structure of their abstract thinking remains intact. In fact, on first impression these patients may seem to have suffered no appreciable disability from their wound apart from a slight clumsiness or slowness. Their articulation of words and their auditory recognition are not affected. The patients are usually able to read and write and have no particular difficulty solving relatively simple intellectual problems. But more careful investigation shows that those suffering from this kind of frontal lesion have defects that are in some ways more serious than the disturbances of specialized operations. These defects are associated with a breakdown of productive activity and active thought. Although the patients have preserved their mental processes almost completely, they cannot actively use them.
The first complaint that we usually encountered with these patients involved the flow of their thoughts. Characteristic were such statements as, “My thoughts will not flow. My head is empty. When I have to write a letter, I don't even know how to begin, and it takes me all day to write.” Our investigations showed that these complaints were in fact based on profound disturbances in the flow of thought.
Patients suffering from this kind of lesion usually reply readily to questions and show no signs of disturbance in their dialogue or in their responses to speech during an examination. But they have considerable difficulty if they are asked to give a detailed and lucid description of a picture, or if they are asked to write an essay on a particular topic. Under these conditions, the patients complain that they have nothing to say, and they find it difficult to go beyond passive description of what they see into the realm of interpretation. It seems impossible for these patients to create an inner concept and develop it by subsequent reasoning.
A number of simple tests bring these difficulties to light. For example, patients with frontal lesions have difficulty producing a smooth train of free associations (cat-dog-horse-cow-chicken). They cannot put together pairs of words whose meanings are logically connected, such as pairing red with its opposite or giving the opposite of low. They cannot produce a complete chain of reasoning, in which the individual links follow from each other, although they can easily draw a logical conclusion from any arguments presented to them. In short, with this kind of lesion, the patients become capable only of passive, reactive behavior. The active flow of their complex psychological processes is disturbed.
Experience showed that a reorganization of thinking in such cases is to a limited extent possible. To achieve it, we had to replace the internal synthesis of psychological processes by a regulation of those processes that depend initially on interaction with another person. Put differently, to overcome the patient's difficulties in active thinking, we used external stimuli to organize and activate his thought. For example, it was found to be characteristic of such disturbances that the patient can tell a story fluently only with the help of successive questions. Sometimes these questions consisted of little more than “What then?” or “What happened after that?” Such questions convert the patient's narrative speech into dialogue and replace his train of thought with successive reactions. These reactions provide links that make it possible for him to transmit his thoughts in a connected way. This finding indicated that patients suffering from this kind of frontal lesion retain the content of their thought and that their difficulties are in the dynamics of their thinking.
The course of therapy required us to use the patient's existing capacities and to discover some way for him to compensate for the missing links in his thought. Since our observations had shown that the patient's speech flows more actively when he is talking to someone else, we began by suggesting that he imagine that he was talking to a person who asked him questions. He would then be conducting his speech as an internal dialogue with an imaginary interlocuter. This device sometimes worked, but it did not always provide enough help. It was more effective to provide the patient with a series of auxiliary signs which could serve as external aids for organizing his narrative. When we instituted this practice, the patient's behavior became like that of a skilled mnemonist who can recall a long series of words with the help of a series of self-generated, internal, auxiliary stimuli, except that in the beginning the patient must rely on external stimuli provided for him. We began by asking the patient to read a passage and make suitable remarks while he read. We then showed him how to use these remarks as auxiliary pegs which he could use to help him organize the narrative. With experience the patient can become quite successful at reproducing tests using this method.
While this method can play an important role in the restoration of smooth narrative speech in patients who are suffering from some kinds of frontal lesion, it is limited in its applicability. It is suitable only for relatively simple narrative speech. What is more, it does not help to restore the active flow of the patients' thought, which normally operates by means of internal connections and cause-and-effect relations, nor does it help them to make transitions from one event to another or from one thought to another. Further aid to the patients' thinking is necessary for the real restoration of narrative speech to occur. In order to work, these aids must in some way create the “experience of transition” and gradually develop into stimuli which the patients can use to generate these dynamic transitions themselves. The method we arrived at for doing this was to give the patient phrases that were transitional formulas. For example, we gave the patient a card on which was written a series of words, such as “however,” “whereas,” “although,” “after,” and “since.” We then asked him to find the necessary transition formulas from those on the card and use them to construct his narrative. We were guessing that at first the card would make the necessary orientation of thought accessible to the patient, but that with practice the patient would begin to produce these transitional formulas for himself.
Our hypothesis was justified, and the use of cards with transitional formulas has often been decisive in restoring considerable smoothness to the flow of narrative speech in such patients. For example, in one case we asked a patient who had great difficulty repeating familiar stories to tell us Tolstoy's story “The Mad Dog.” The patient was given a card on which the transitional formulas were written to help him compensate for his difficulties. He carefully examined the card and then told the story fully and fluently. The story began as follows, with the formulas used by the patient appearing in italics: “Once upon a time a rich man bought a small puppy and when it grew up the rich man took it hunting with him. Once a mad dog came into the garden where the children were playing. The rich man saw it and began to shout, the children heard and ran to meet the mad dog. Then the man's own dog appeared, and they began to fight.”
The effect of using the transitional formulas was to create the necessary links between the action being described at the present moment and the next meaningfully connected action. In terms of our general theory, the transitional formulas create necessary intentions; the patient both selects a meaningful next step and uses that step as a goal to reach the following step. The general idea of the story and the task of remembering it make up a general plan of behavior within which the individual phrases are subgoals, each requiring that the patient carry out current action in terms of the necessary next steps that the overall plan dictates. Within this framework the transition formulas take on the function of intentional links.
In this example the use of the formulas was external. During the following months the patient's powers of description and narrative became reorganized, and new transitional formulas appeared spontaneously. His narration became more continuous, and particularly important, his written accounts of passages that had been read to him ceased to show any signs of pathology. In addition, he was able to describe the contents of pictures spontaneously, which he had been unable to do previously.
This method of restoring active thinking is roughly analogous to the level of restoration of individual words and phrases in afferent aphasia. The suggested formulas for transitions are useful when the subject matter to be transmitted is sufficiently obvious to the patient whose only defect is in his dynamic patterns of thought. But the formulas are inadequate in cases where the patient does not understand the plan of the story and must reconstruct the meaning for himself.
It is as if the pieces of a jigsaw puzzle are piled up haphazardly before these patients, who can see no general pattern and who cannot arrange them in their proper sequence. “I can see one piece here, one piece there, and another there,” said one of our patients, “but I cannot grasp the general plan.” The spontaneous thought of these patients is disrupted not only because they have an absence of intention and cannot orient their thought, but also because they cannot mentally make the necessary plans to arrange the details of the narration in their proper order. We have helped patients compensate for this defect by reorganizing the processes of planning a composition so that it becomes externalized. Our technique for teaching these patients how to plan a composition is to have them write the fragments of narration they remember on separate pieces of paper without paying any attention to the order in which they are written. They then try to order these fragments by rearranging the pieces of paper, which are all laid out in front of them where they can be seen at once. In ths way the plan of a composition is broken down into two successive stages: deciding on the individual fragments to write and then arranging them in a coherent order.
We had striking results with several of our patients when using this method, which we called the “Index card plan.” The following example illustrates how the method worked. We read Tolstoy's story “How the Thief Gave Himself Away” to a patient who found it extremely difficult to retell the story. We then instructed him to write down on cards all the fragments of the story he could remember and to arrange them in order. Finally we asked him to write the story. He performed the first two steps as follows:
1. How he began to sneeze and gave himself away.
2. Once a thief wished to rob a strange merchant.
3. When they were in the attic and found nobody.
4. The merchant told a workman that somebody had climbed up into the attic.
5. How the thief hid in the pile of tobacco.
1. Once a thief wished to rob a strange merchant.
2. The merchant told a workman that somebody had climbed up into the attic.
3. How the thief hid in the pile of tobacco.
4. When they were in the attic and found nobody.
5. How he began to sneeze and gave himself away.
After he had composed this plan, the patient told the story lucidly and fluently. “Before all five sentences were turning over in my head, one after the other, and I did not know what to discard,” the patient explained, “but now I think about only one sentence at a time and everything works out properly.”
Later we asked this patient to write the story of how he was wounded. He wrote three lines and then insisted he could write no more. All of our attempts to prompt him to continue were unsuccessful. The patient refused to go on, saying he could not sort out the chaos that was in his head. Once again we suggested he use the index card plan method. In the course of the next hour he wrote down fourteen different sentences as he remembered them without bothering to put them in any order. Then he arranged them and wrote the following account of how he was wounded:
On 11 December 1942, I was in the front line. It had been cloudy since the morning, snow was falling and there was a slight breeze. I was at the command post accompanied by the senior political agent, comrade P. and a few soldiers. There was a little artillery fire. The soldiers began to ask me if we should soon open fire on the enemy. I told them the time had not yet come. An hour later the command to open fire was given. At this time the soldiers were in good heart and we had suffered no losses. I observed that the shells burst on the enemy's positions.
At 4 p.m. I was severely wounded in the head. I can remember comrade P. saying that the commander had been killed. I could not tell him I was alive, but I was thinking how easy it was to die ... then I remember no more.
How they took me to hospital I do not know. I can remember them taking me from an airplane, at the airport at the town V. Then I realized that the Surgical Hospital was in this town, and an operation was performed on me. When I reached the hospital in V., the surgeon came on his round and told me that the operation would be done in the evening. That was 13 December 1942. Evening came, the orderlies took me to the operating theater and put me on the table; it was very difficult to lie down and I only asked how quickly the operation would be over. They told me: “Just be patient a little longer,” but of course I had to go through with it all.
The use of this method never quite became automatic for the patient, and a long time elapsed after his discharge from the hospital before he could use it to write a report to his commanding officer.
These examples represent only fragments from the thousands of cases I have analyzed over the years. In each case the progress of diagnosis and the methods of treatment bear an obvious and close relation to the principles put forth by Vygotsky, who first suggested that the dissolution of higher psychological functions could serve as a path for their analysis. I think the examples show clearly both the logic of our general approach to the analysis of higher psychological functions and the important link between diagnostic theory and restorative practice. The methods of therapy that have proved useful are exactly those methods that would have been predicted by Vygotsky on the basis of the general theory of the soclohistorical origins of higher psychological functions. This work, carried out with the assistance of dozens of highly talented researchers, occupied my attention for more than twenty-five years. The work is still incomplete. A great deal remains to be done in order to perfect the methods that we developed. But a foundation for future progress has been laid.